18 - 3rd Party Drug Plans Flashcards
1
Q
Why are costs to plans increasing?
A
- Aging population
- Biologics
- Specialized medications
2
Q
What is a preferred provider network (PPN)?
A
Agreement between a payer/ employer and a provider/ pharmacy to provide products or services at a lower cost than competitors
3
Q
What is a closed PPN?
A
Plan members limited to a pharmacy
4
Q
What is an open PPN?
A
Plan members may go to other pharmacies but may pay a co-pay
5
Q
How are private payers saving money?
A
- Mandatory generic substitution
- Prior approvals on high cost specialty products
- Capping or reducing fees
6
Q
What are plan sponsors?
A
- Employers, unions, associations
- Pay the benefits claimed
7
Q
Describe the difference between insurance companies and adjudicators
A
- Insurance companies (insurers or carriers) -> design and monitor plans; recruit plan sponsors
- Adjudicators -> adjudicate online claims, review formularies and make recommendations; audit claims
8
Q
What do auditors review?
A
- Unintentional infractions
- Claims not submitted correctly
- Claims that don’t meet the agreement requirements
- Intentional infarctions
- Claims that are fraudulent (product/ services not provided, kickbacks, treating outside scope of practice)
9
Q
Describe pharmacy audits
A
- Audit programs confirm the integrity and accuracy of the data submitted to the claim
- Auditors ensure that the agreement terms between the pharmacy and the plan are being adhered to
- Adjudicators may manage the plan for another organization (Telus for GWL) or a plan may have their own adjudicator (Green Shield)
10
Q
Reasons for audits
A
- Claims are submitted improperly
- Claims don’t meet agreement signed between pharmacy and plan
- Claims are submitted fraudulently (intentional deception or misrepresentation)
- Billing for services not rendered
- Billing for services outside the scope of practice
- Accepting “kickbacks” or referral payments
- Over-treatment
11
Q
Reasons for NIHB audits
A
- Detect and recover claim irregularities
- Ensure there is a valid prescription order
- Ensure appropriate billing
- Actual purchase costs of drugs charged
- Drug mark-ups are based on provincial or territorial schedules
- U and C fee not exceeded
12
Q
What triggers audits?
A
- Higher than average fees and drug costs
- Charging cost differences to px
- Unusual quantities/ short days supply
- Unlikely therapies (for age, gender, odd combinations)
- Forcing adjudication
- Frequent “no-sub” prescriptions
- Using more than one override code/ frequent overriding of response codes
- Multiple over-ride attempts
- Compounding ingredients/ costs for compounding
- Inappropriate days supply for chronic medications
13
Q
Importance of preventing audits
A
- Financial risk to the business
- Operational costs
- Preparation for the audit costs employee time
- Employee costs during the audit
- Reputation of the business (word gets around of the audit/ “clawbacks”)
- May have electronic billing privileges rescinded if major issues occur
14
Q
Reasons for “claw-backs”
A
- Verbal refill authorizations/ verbal prescriptions not documented clearly
- Failure to be able to produce documentation
- No evidence of physician authorization/ no authorized repeats
- Early refills/ unauthorized vacation supplies
- Not an eligible benefit
- Quantity supplied greater than what was authorized
- No proof of prescriber indicating “no-sub”
- Prescription not dated
- Excessive time charges on compounds
- Ingredient price overcharge on compounds
15
Q
Describe ways to prevent “claw-backs” with compliance packaging
A
- Must document who requested the compliance packaging
- Actual days supply must be indicated on the prescription along w/ specific directions from the physician
- Proof of authorization from the prescriber indicated frequency of filling must be indicated on the prescription
